Customer Service Human Resources
Resume:
Shelley Garcia
Cape Coral, Florida 33904
Education Concordia College
St. Paul, MN
BA Organizational Management and Communications,
1991
Lakewood Community College
White Bear Lake, MN
AA Business, 1989
PC Skills Microsoft Outlook, Power Point, Word, Excel
Employment Prestige Health Choice
Doral, FL
August 2006- April 2010 Director Provider/Hospital Relations
. Instrumental in the start up of a Medicaid Managed
Care Health Plan which is equity owned by nine
Federally Qualified Health Centers (FQHC) in the
state of Florida.
. Created Policies and Procedures for Provider
Relations department based on AHCA compliance
standards, provider contracting and service
strategies. A maximum of efficiencies in utilization
of human and financial resources was exercised
throughout endeavor.
. Participated in Agency for Healthcare Administration
(AHCA) audit and was awarded on the first survey with
a 98% approval to operate as a provider service
network (PSN).
. Strategize, recruit, negotiate and contract hospital,
ancillary and provider network in five counties which
resulted in an enrollment of 40, 050 of members in a
duration of one year.
. Ensures compliance with the government programs such
as Medicaid/Medicare for all contracting and network
development purposes.
. Establishes effective departmental practices and
works closely with various departments ensuring
contracts meet operating, financial and legal
standards.
Amerigroup Corporation (formerly PHP)
Tampa, FL
June 2004 to May 2006 Ancillary Contract Manager
. Responsible for ensuring appropriate oversight and
management of programs are operating for the
statewide ancillary provider network. Report to Vice
President of Provider Operations.
. Interface with Medical Directors and RN staff
regarding the implementation and monitoring of high
risk OB and Asthma Programs for the assigned Medicaid
population.
. Communicate and orient Provider Relations/Medical
Management on any unique program or contract
arrangements for accurate administration.
. Identify opportunities in over utilization in terms
of overpayments for non-covered benefits, billing
abuse and fraud. In 2005 I personally identified 1.5
million which resulted in 90% recoup of over
payments.
. Successfully re-contracted entire ancillary network
to reduce rates which provided corporation with a 2.2
million dollar savings annually.
. Develop programs for oversight of Quality Monitoring
for all major ancillary providers to ensure providers
are meeting the performance expectations and
standards set by Amerigroup.
. Extensive travel.
Amerigroup Corporation
Tampa, FL
April 2001 to 2004 Provider Relations Account Executive
(formerly PHP)
. Evaluated and analyzed medical loss ratio of each
primary care provider and specialty provider in
network for profitability, utilization, and provider
performance.
. Intervened and convinced a key pediatric provider to
rescind a termination notice initiated due to its
dissatisfaction with certain management decisions.
The net result was the Plan maintained its contract
with key provider as well as re-contracted
exclusively which increased membership by 1200.
. Strengthened and developed alliances with key
specialist providers in the service area that
resulted in a marketable network of competitively
contracted health care providers.
. Identified and educated providers not meeting quality
measurements defined by the state.
Florida Health Choice, Inc.
Delray Beach, FL
1997 to 2001 Provider Relations Representative
. Identified, recruited, and contracted providers for
Lee and Hendry county expansion.
. Performed site surveys for quality compliance.
. Interacted with the Agency for Health Care
Administration for necessary requirements for state
approval for the Plan to expand to new markets
. Created Power Point presentation slides for all
products for educations purposes.
. Made large/small group presentations for providers
for the purpose of product orientation.
. Maintained and serviced several large vendor
contracts for Behavioral Health, vision, and dental.
. Saved Plan $750,000 in Medicaid payments after an in-
depth audit of the provider eligibility reports,
capitation report and key edits in the Plans
information system revealed that providers were being
paid capitation for members that were subsequently
determined to be ineligible for coverage by the
Agency for Health Care Administration (AHCA). The
error involved all seven of the Plans Medicaid
counties. The system edit was corrected and the Plan
recouped 100% of all over payments.
Allina Health System
Minnetonka, MN
1996 to 1997 Physician Field Representative
. Managed and maintained strong working relationships
with providers in a designated territory.
. Resolved operational issues concerning contract
administration, claims adjudication, and monitor cash
advances involving other Allina staff as required.
. Identified newly contracted providers for the purpose
of orientation and training of Medica products and
policy/procedures.
. Performed annual site visits for the clinics and
physicians to evaluate administrative practices for
efficiency and quality.
. Remained knowledgeable of provider contracting
strategy and apply this information to the provider
relationship.
United HealthCare Corporation (ASO to Allina Health
System)
Edina, MN
1995 to 1996 Contracts Specialist
. Identified, recruited, and contracted dental
providers for state public programs and commercial
expansion.
. Analyzed demographics and utilization reports for
high volume Medicaid providers and service usage.
. Made presentations to providers to educate them on
the Medica Choice Care product and the contract
provisions.
. Contributed to departmental budget.
. Participated in fee review committee.
. Provided interface necessary for the administration
of medical/dental related benefits.
. Traveled extensively to non-metro areas.
PCA Health Plans of Texas
San Antonio, TX
1994 to 1995 Marketing Representative
. Identified and contacted individual Medicare
beneficiaries and senior citizen groups.
. Developed and conducted individual and group
presentations for prospective Qualicare members.
. Assisted interested persons in completing the
necessary enrollment forms.
. Established and maintained administrative files of
all contacts made and the results of those calls and
presentations.
. Participated in events and promotions.
Blue Cross/Blue Shield of Minnesota
Eagan, MN
1991 to 1994 Claims/Membership/Customer Service Specialist
. Researched and responded to telephone or written
inquiries for the claims, customer service, and
membership issues.
. Coordinated and communicated with claims and
membership personal on resolutions to the customer
inquiries.
. Administered client specific contract benefits,
researched and resolved all system edits, and ensured
timely and accurate payment.
. Maintained a working knowledge of medical
terminology, ICD9, CPT/HCPC coding.
HealthEast
St. Paul, MN
1988 to 1991 Customer Claims Representative
. Completed all third party forms and itemized bills
for patients and insurance companies.
. Responded to credit inquiries and implemented
corrections.
. Recorded customer accounts on CRT
. Interfaced with contracted HMO's and insurance
companies.
. Researched patient inquiries and facilitated
satisfactory conclusions.
HealthEast
St. Paul, MN
1987 to 1988 Human Resources Float
. Assisted with Human Resources Information Systems
(HRIS) conversion.
. Performed audits for problems related to employee
vacation and seniority levels.
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